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Objective Total exercise duration and abnormal QRS score values are treadmill exercise testing (TET) prognostic parameters that have been shown to be significantly and independently associated with cardiac mortality. We evaluated the prognostic value of a new index (M score, Michaelides score) incorporating TET duration and QRS score values in a simple index. Methods In this study, we included 626 patients, who underwent TET and coronary arteriography. Cardiac catheterization showed the presence of coronary artery disease in 64.3% of these patients. The M score was calculated by adding the value of the Athens QRS score to the duration of TET (in minutes). The outcome measure was a composite of myocardial infarction or death. Patients were prospectively followed for 38 +/- 21 months (median 36 months). Results The composite endpoint was more frequent among the patients of the 1st quartile (M-score values < - 5.8). In univariate analysis, mortality of the first-quartile patients was significantly higher (14 vs. 1.1%, P

Background: The appearance of a discrete upward deflection of the ST segment termed “the ST hump sign” (STHS) during exercise testing has been associated with resting hypertension and exaggerated blood pressure response to exercise. Objective: We investigated the prevalence and clinical significance of this sign in a population of patients with hypertrophic cardiomyopathy. Methods: Eighty-one patients with hypertrophic cardiomyopathy (HCM) who underwent cardiopulmonary exercise testing were followed in a retrospective cohort study for a mean period of 5.3 years. Results: The appearance of the STHS at the peak of exercise testing was observed in 42 patients (52%), particularly in the inferior and the lateral leads. Patients with the STHS had higher fractional shortening and maximum left ventricular wall thickness and exhibited more frequently outflow tract gradient > 30 mmHg at rest. Furthermore, the presence of STHS was a strong independent predictor of the risk of sudden cardiac death (SCD), as the latter occurred in eight of the patients with this sign (8/42, 19%) and in none of the patients without it (0/39, 0%) (P < 0.001). Conclusion: The appearance of a “hump” at the ST segment during exercise testing appears to be a risk factor for SCD in patients with HCM. However, further studies are necessary to validate this finding in larger populations and to elucidate the mechanism of the appearance of the “hump.” Ann Noninvasive Electrocardiol 2009;14(2):158-164.

Background: Heart rate recovery (HRR) has been identified as a reliable predictor of cardiac mortality, correlated with autonomic tone. In a model of sequential exercise testings, we investigated the reproducibility of HRR and the association between HRR modification and myocardial adaptation to ischemia. Methods: We studied 128 patients (mean age 62 +/- 9 years, 83% males) with angiographically documented coronary artery disease (CAD) and a first positive exercise testing, who agreed to undergo a second exercise testing after 24 hours. Results: HRR was increased from 25 +/- 10 beats/min at the first exercise testing to 30 +/- 13 beats/min at the second exercise testing (P < 0.001). Thereafter, participants were divided into two groups: Group I comprised 88 patients who presented augmentation of the HRR in the first compared to the second exercise testing, while group II comprised 40 patients who presented unchanged or reduced HRR. The rate-pressure product (RPP) at 1 mm ST-segment depression (ischemic threshold) at the second compared to the first exercise testing were significantly improved in group I patients (2345 +/- 3429 mmHg/min), while it was worsened in group II patients (-630 +/- 2510 mmHg/min) (P < 0.001). Conclusions: In a model of sequential exercise testings, myocardial adaptation to exercise-induced ischemia was associated with favorable modification of HRR.

Background: It has been previously postulated that Thallium-201 (Tl-201) scintigraphy is characterized by relatively low specificity in hypertensive patients. This study was undertaken to assess any possible influence of false-positive scintigraphic results on the prognosis of hypertensive patients. Methods: The study group comprised 179 consecutive hypertensive patients (128 men and 51 women), aged 50 7 years, who underwent exercise Tl-201 scintigraphy and coronary angiography (patients with normal scintigraphic results underwent coronary angiography due to persistent angina-like symptoms). All patients with normal coronary arteries underwent a second Tl-201 scintigraphy within 36 +/- 6 months. Patients with reversible ischemia in the second scintigraphy underwent also a second coronary angiography. Results: Coronary artery disease (CAD) was detected in 78 (44%) patients, while the rest 101 (56%) patients had normal coronary arteries. Abnormal scintigraphic results were revealed in 66 (85%) patients with CAD and in 38 (38%) patients without CAD. Twenty-two (58%) of the 38 hypertensive patients with false-positive scintigraphic results presented reversible ischemia of the infero-posterior wall of the left ventricle. Coronary artery disease was detected in 7 (32%) of these patients during the follow-up period. Conclusions: Hypertensive patients with normal coronary arteries and false-positive scintigraphic results usually present with reversible ischemia of the infero-posterior wall of the left ventricle. This group of patients seems to be at increased risk of developing CAD in a long-term follow-up period. (c) 2006 Elsevier Ireland Ltd. All rights reserved.

Objective The accuracy of treadmill exercise testing to detect coronary artery disease is limited in women. This study was undertaken to evaluate whether QRS score can improve the accuracy of treadmill exercise testing in women. Methods The study population consisted of 114 women with angina-like symptoms, who underwent both treadmill exercise testing and coronary angiography. The impact of QRS score on the standard ST-segment based diagnostic ability of treadmill exercise testing to detect coronary artery disease was studied. Results Incorporation of QRS score in standard ST-segment diagnostic criteria significantly enhanced sensitivity (from 59 to 80%), specificity (from 40 to 94%) and diagnostic accuracy (from 50 to 87%) of treadmill exercise testing. The QRS score was shown to reduce significantly the false-positive results from 60 to 6%. Furthermore, QRS score accuracy was correlated with the extent of coronary artery disease. The diagnostic ability of QRS score was greater both among patients with normal and impaired systolic function of the left ventricle. Conclusions QRS score can improve the limited diagnostic accuracy of treadmill exercise testing in women, by predominantly decreasing the high prevalence of false-positive results.

To evaluate the improvement of diagnostic ability of exercise testing to detect multivessel coronary artery disease in patients with extended Q-wave anterior myocardial infarction, using additional right-sided chest leads. Fifty-two consecutive patients with Q-wave anterior myocardial infarction underwent exercise testing, using the standard 12 and the additional right-sided (V3R, V4R, V5R) chest leads, thallium-201 scintigraphy and coronary arteriography. Twenty-one (40%) patients had one-vessel disease, 18 (35%) had two-vessel disease and 13 (25%) had three-vessel disease. The sensitivities of the standard 12-lead exercise testing and its combination with the additional right-sided chest leads were 24% (5/21) versus 28% (6/21) for the detection of one-vessel disease (P:NS), 33% (6/18) versus 83% (15/18) for the detection of two-vessel disease (P < 0.05) and 38% (5/13) versus 92% (12/13) for the detection of three-vessel disease (P < 0.05), respectively. In thallium-201 scintigraphy, 29 of the 31 (94%) patients with multivessel coronary artery disease reversible ischemia. The usual 12-lead exercise testing could detect ischemia in 11 (35%) of these 31 patients, while the addition of the right-sided chest leads could detect ischemia in 27 (87%) of them (P < 0.05). The additional right-sided chest leads significantly improve the low sensitivity of the usual exercise testing to detect multivessel coronary artery disease in patients with previous extended Q-wave anterior myocardial infarction.

Background: Ischemic preconditioning (IP) is a cardioprotective phenomenon, induced by brief episodes of myocardial ischemia, which is supposed to affect not only the myocardium, but also the entire cardiovascular system. Considering that patients with coronary artery disease (CAD) have also been described to present impaired aortic mechanical properties, we tried to investigate the possible influence of the late phase of IP on aortic distensibility in patients with CAD. Methods: Fifty patients, aged 48 to 72 (mean, 57 6 years), with angiographically confirmed CAD and exercise-induced myocardial ischemia, underwent two treadmill exercise testings (ETs). The second ETs was performed the next day. Thallium-201 scintigraphy was performed during the first and the second ET. Aortic distensibility was evaluated before each exercise testing by a non-invasive technique, using two-dimensional guided M-mode transthoracic echocardiography and arterial pressure was measured simultaneously at the brachial artery by sphygmomanometry. Results: The patients were divided in 2 groups according to the extent of myocardial ischemia at peak exercise of the second test, compared to the first test. In 35 (70%) of the studied patients ischemia signs were reduced during the second ET (Group A), while in the rest 15 (30%) of the patients (Group B) no improvement or even worsening of the observed ischemia signs was demonstrated by the studied exercise parameters and the extent of myocardial ischemia in thallium-scintigraphy. Increased aortic distensibility during the second measurement was found in 33 (94%) of the 35 patients of Group A but only in 1 (7%) of the 15 patients of Group B. Aortic distensibility was found to be significantly improved in patients of Group A, while it was found to be worsened in Group B patients. Conclusions: The aortic distensibility alteration could be used as an index of influence of ischemic preconditioning to exercise-induced myocardial ischemia, which could be considered indicative of the systemic effects of IP in humans. (c) 2005 Elsevier Ireland Ltd. All rights reserved.

Background: The aim of this study was to evaluate the contribution of QRS prolongation in the diagnosis of coronary artery disease (CAD) in patients with exercise-induced ST-segment depression exclusively during the recovery period. Methods: The study population consisted of 107 patients (90 males and 17 females) aged 39-70 (mean 59 +/- 7) years who underwent a treadmill exercise test using Bruce protocol and presented ST-segment depression limited to the recovery period. Angiographic data were available for all studied patients. Results: Among studied patients, 74 (69%) were found to have hemodynamically significant CAD, while the remaining 33 (31%) had normal coronary arteries. Concomitant QRS prolongation was revealed in 61 (82%) of the patients with angiographically documented CAD, while in 13 (18%) patients QRS duration remained unchanged. On the contrary, only 4 (12%) of the 33 patients with normal coronary arteries showed prolonged QRS duration during ST depression, while in the remaining 29 (88%) QRS duration remained unchanged. Conclusions: The evaluation of the concomitant QRS duration changes may discriminate patients with truly ischemia-induced ST-segment depression limited to the recovery period.